A client gave birth 2 days ago and is preparing for discharge. The nurse assesses respirations to be 26 breaths/min and labored, and the client complains of chest pain & short of breath ambulating from the bathroom this morning. Lung sounds are clear. The nurse alerts the primary care provider and the nurse- midwife to her concern that the client may be experiencing:

pulmonary embolism.

mitral valve collapse.

upper respiratory infection.

thrombophlebitis.

Answer and Explanation

The Correct Answer is A

A. Pulmonary embolism (PE): PE is a life-threatening condition that occurs when a blood clot travels to the lungs, often originating from a deep vein thrombosis (DVT). Postpartum clients are at increased risk due to hypercoagulability. Symptoms include sudden-onset dyspnea, chest pain, tachypnea, tachycardia, and hypoxia despite clear lung sounds. This warrants immediate intervention.

B. Mitral valve collapse: This is not a common postpartum complication and does not explain the client’s acute symptoms.

C. Upper respiratory infection: URIs present with cough, congestion, fever, and abnormal lung sounds, which this client does not have.

D. Thrombophlebitis: This refers to localized inflammation of a superficial vein, which may cause leg pain and swelling but does not typically result in respiratory distress.

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Correct Answer is A

Explanation

A. Correct. The priority is to assess the fundus for firmness and location. Uterine atony is a common cause of postpartum hemorrhage and requires immediate assessment and intervention.

B. Incorrect. Increased bleeding in a multiparous client should not be dismissed as normal without assessment.

C. Incorrect. Administering Pitocin may be appropriate but should follow an assessment of the fundus first.

D. Incorrect. Waiting an hour without assessing the fundus could delay necessary interventions for postpartum hemorrhage.

A. She may have outbursts of anger B. She may harm her infant C. She may lose interest in her husband D. She may neglect her hygiene

Correct Answer is B

Explanation

A. She may have outbursts of anger: Possible but not the primary concern.

B. She may harm her infant: Correct. Postpartum depression can lead to severe thoughts of harming oneself or the baby, requiring immediate medical intervention.

C. She may lose interest in her husband: While possible, it is not the primary safety concern.

D. She may neglect her hygiene: This can occur but is not the most immediate concern compared to potential harm to the infant.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A 25 year-old woman gave birth to her second child 6 hours ago. She informs the nurse that she is bleeding more than with her previous birth experience. The initial nursing action is to:

Correct Answer is A

Explanation

When a woman is diagnosed with postpartum depression, what is one of the main concerns?

Correct Answer is B

Explanation

A nurse is caring for a client who is 1 hr postpartum following a vaginal birth of a newborn weighing 9 lb 6 oz. (4252 g). The nurse should recognize that this client is at risk for which postpartum complication?

When discussing the need to support the lower uterine segment, which statement by the new nurse indicates understanding.

The nurse is preparing a care plan for her 12-hour postpartum patient which include prevention of thrombosis. During implementation, the nurse is expected to

The nurse is teaching prenatal clients about the benefits of skin to skin. Which statement made is correct?

The nurse can differentiate a new father is experiencing engrossment when she notices which behavior?

Exhibits The nursing priority is to dropdown

The nurse is assessing a postpartum patient who had an uncomplicated vaginal delivery one hour ago. Which assessment finding requires immediate intervention?

A breastfeeding mother expresses concern about whether her one-week-old newborn is getting enough milk. Which finding is a concrete indicator that the baby is getting enough milk?